Provider Demographics
NPI:1780913756
Name:CAMELOT CARE CENTERS, INC
Entity type:Organization
Organization Name:CAMELOT CARE CENTERS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:KEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-773-1985
Mailing Address - Street 1:5901 N PROSPECT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4395
Mailing Address - Country:US
Mailing Address - Phone:309-692-1095
Mailing Address - Fax:309-692-1375
Practice Address - Street 1:5901 N PROSPECT RD STE 101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4395
Practice Address - Country:US
Practice Address - Phone:309-692-1095
Practice Address - Fax:309-692-1375
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAMELOT CARE CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2B05-IPI-141Medicaid